Increased inpatient mortality in patients hospitalized for atrial fibrillation and atrial flutter with concomitant amyloidosis: Insight from National Inpatient Sample (NIS) 2016-2017.

PURPOSE: Using National Inpatient Database (NIS), comparison of clinical outcomes for patients primarily admitted for atrial fibrillation/flutter with and without a secondary diagnosis of amyloidosis was done. Inpatient mortality was the primary outcome and hospital length of stay (LOS), mean total hospital charges, odds of undergoing cardiac ablation, pharmacologic cardioversion, having a secondary discharge diagnosis of heart block, cardiogenic shock and cardiac arrest were secondary outcomes. METHODS: NIS database of 2016, 2017 was used for only adult hospitalizations with atrial fibrillation/flutter as principal diagnosis with and without amyloidosis as secondary diagnosis using ICD-10 codes. Multivariate logistic with linear regression analysis was used to adjust for confounders. RESULTS: 932,054 hospitalizations were for adult patients with a principal discharge diagnosis of atrial fibrillation/flutter. 830 (0.09%) of these hospitalizations had amyloidosis. Atrial fibrillation/flutter hospitalizations with co-existing amyloidosis have higher inpatient mortality (4.22% vs 0.88%, AOR: 3.92, 95% CI 1.81-8.51, p = 0.001) and likelihood of having a secondary discharge diagnosis of cardiac arrest (2.40% vs 0.51%, AOR: 4.80, 95% CI 1.89-12.20, p = 0.001) compared to those without amyloidosis. CONCLUSIONS: Hospitalizations of atrial fibrillation/flutter with co-existing amyloidosis have higher inpatient mortality and odds of having a secondary discharge diagnosis of cardiac arrest compared to those without amyloidosis. However, LOS, total hospital charges, likelihood of undergoing cardiac ablation, pharmacologic cardioversion, having a secondary discharge diagnosis of heart block and cardiogenic shock were similar between both groups.

Nasolabial and extended nasolabial flaps for reconstruction in oral submucous fibrosis.

OBJECTIVES: The objective of the study was to evaluate the results of nasolabial/extended nasolabial flaps as a modality for treatment of oral submucous fibrosis. MATERIALS AND METHODS: Eleven patients of Stage III or IVa maximum interincisal opening were selected to be operated. Nasolabial/extended nasolabial flaps were done for both the sides. All of the flaps were done in a single stage and were inferiorly based. A similar flap harvest/surgical technique was utilized for all the cases. RESULTS: The preoperative mouth opening ranged from 5 to 16 mm, with a mean of 10.09 mm. At 6 months the mouth opening ranged from 29 to 39 mm. Some of the complications encountered were poor scar, wisdom tooth traumatising the flap, decreased mouth opening due to non compliance and too much bulk. All of theses were managed satisfactorily. CONCLUSION: The nasolabial flap is a very reliable flap to restore the function of oral cavity. Important adjuvant measures are habit cessation, lifestyle changes, and aggressive physiotherapy.

Coronary-Cameral Fistula Connecting the Left Anterior Descending Artery and the First Obtuse Marginal Artery to the Left Ventricle: A Rare Finding.

Coronary-cameral fistulas are rare congenital malformations, often incidentally found during cardiac catheterizations. The majority of these fistulas are congenital in nature but can be acquired secondary to trauma or invasive cardiac procedures. These fistulas most commonly originate in the right coronary artery and terminate into the right ventricle and least frequently drain into the left ventricle. Depending upon their size and location, coronary-cameral fistulas can lead to congestive heart failure, myocardial infarction, and bacterial endocarditis. We describe a case of 49-year-old woman who presented with worsening exertional dyspnea and leg swelling. Transthoracic echocardiogram revealed an ejection fraction of 35%. Cardiac catheterization demonstrated a fistula connecting the left anterior descending artery and the first obtuse marginal artery to the left ventricle. In this report, the authors provide a concise review on coronary fistulas, complications, and management options.

Speckle Tracking Echocardiography of the Right Atrium: The Neglected Chamber.

The right atrium (RA) plays a pivotal role in electromechanical and endocrine regulation of the heart. Its peculiar anatomical features and phasic mechanical function make it distinct from ventricles. Various invasive and noninvasive techniques have been used to elucidate RA structure and function. Of these modalities, echocardiography has distinct advantages over others. Several conventional measures of RA function through echocardiography have been described in the literature, but they are load dependent. A relatively new technique is speckle tracking-derived strain, which is relatively less dependent on loading conditions. Speckle tracking echocardiography tracks acoustic scatters (speckles) of myocardium frame-by-frame to calculate strain or deformation of the myocardium. Speckle tracking echocardiography has been used extensively for strain assessment of the right and left ventricle to detect subtle disease pathology, to gain mechanistic insight, as a marker of ischemic metabolic memory, as an endpoint in clinical trials, and as a functional assessment tool. The RA is a relatively neglected chamber, as it is mostly studied for assessment of atrial mass lesions, for electrophysiological studies, and in animal models for physiological assessment. However, its role in the systolic and diastolic function of the right heart, pulmonary vascular pathology, congenital heart diseases, and combined electromechanical activation phenomena has been less explored or unexplored. Speckle tracking echocardiography is an ideal tool for the assessment of the RA because of its regional and global functional characterization, angle independence, and high temporal resolution.

Giant Thoracic Aneurysm Following Valve Replacement for Bicuspid Aortic Valve.

Bicuspid aortic valve is a common congenital anomaly associated with aortopathy, which can cause aortic root dilatation, necessitating regular screening if the aortic root is > 4.0 cm. Despite the low absolute incidence of aortic complications associated with bicuspid aortic valve in the general population, the consequences of such complications for an individual patient can be devastating. Herein we propose a balanced algorithm that incorporates recommendations from the three major guidelines for follow-up imaging of the aortic root and ascending thoracic aorta in patients with a bicuspid aortic valve, maintaining the current recommendations with regard to surgical thresholds.

Traumatic Tension Pneumothorax as a Cause of ICD Failure: A Case Report and Review of the Literature.

Background. Tension pneumothorax can infrequently cause ventricular arrhythmias and increase the threshold of defibrillation. It should be suspected whenever there is difficulty in defibrillation for a ventricular arrhythmia. Purpose. To report a case of traumatic tension pneumothorax leading to ventricular tachycardia and causing defibrillator failure. Case. A 65-year-old African-American female was brought in to our emergency department complaining of dyspnea after being forced down by cops. She had history of mitral valve replacement for severe mitral regurgitation and biventricular implantable cardioverter defibrillator inserted for nonischemic cardiomyopathy. Shortly after arrival, she developed sustained ventricular tachycardia, causing repetitive unsuccessful ICD shocks. She was intubated and ventricular tachycardia resolved with amiodarone. Chest radiograph revealed large left sided tension pneumothorax which was promptly drained. The patient was treated for congestive heart failure; she was extubated on the third day of admission, and the chest tube was removed. Conclusion. Prompt recognition of tension pneumothorax is essential, by maintaining a high index of suspicion in patients with an increased defibrillation threshold causing ineffective defibrillations.

Fronto-orbital advancement and total calvarial remodelling for craniosynostosis.

OBJECTIVE: To describe the results of fronto-orbital advancement and remodelling for craniosynostosis in children. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Department of Plastic Surgery, Combined Military Hospital, Rawalpindi, from June 2009 to June 2012. METHODOLOGY: All the patients with cranial suture synostosis operated were included in the study. Those patients who were lost to follow-up were excluded. Variables considered were age, gender, type of synostosis, intracranial pressure, and history of previous surgeries for the same problem. Outcome measures were studied in terms of improvement of skull measurements (anteroposterior and bicoronal), duration of surgery, hospital stay, blood transfusions, complications and parents satisfaction. RESULTS: A total of 36 patients were included in the study. Male to female ratio was 3:1. The age ranged from 5 to 54 months. Thirty two patients presented with non-syndromic and four with syndromic craniosynostosis. Fronto orbital advancement and total calvarial remodelling was done in 26 and 10 patients respectively. There was improvement in the skull measurements and the parents were satisfied in all cases with the skull shape. Complications occurred in 11.1% including chest and wound infection and one death. CONCLUSION: Fronto-orbital advancement and remodelling is an effective procedure for the correction of craniosynostosis, however, individual cases may require other procedures like total calvarial remodelling.

Painful palpitations: chest pain associated with postextrasystolic ST depression.

Postextrasystolic T-wave changes have been described as early as 1915. The significance and mechanism of such changes remain controversial. Because postextrasystolic ST changes are rare, much of the ensuing discussion concentrates on the closely related and more commonly reported phenomenon of postextrasystolic T-wave inversion. This report documents the case of a 67-year-old man with a history of coronary artery disease who was admitted to the hospital with chest pain.

Reoperation for intracranial hypertension in TWIST1-confirmed Saethre-Chotzen syndrome: a 15-year review.

BACKGROUND: Saethre-Chotzen syndrome is a syndromic craniosynostosis defined by a genetic mutation affecting the TWIST1 gene on chromosome 7p21. It is typically associated with unicoronal or bicoronal synostosis, eyelid ptosis, dysmorphic external ears, and other variable facial and limb abnormalities. Surgical management of the craniosynostosis addresses the calvarial deformity and may relieve or reduce the risk of intracranial hypertension. The aim of this study was to assess surgical intervention, with particular consideration of the reoperation rate for intracranial hypertension, in Saethre-Chotzen syndrome patients. METHODS: A retrospective case note analysis was performed on all patients with a confirmed TWIST1 gene abnormality who attended the Oxford Craniofacial Unit over a 15-year period. Each patient's mutation and clinical features were recorded. Surgical intervention and sequelae were examined in greater detail. RESULTS: Thirty-four patients with genetically confirmed Saethre-Chotzen syndrome were identified. All had craniosynostosis (bicoronal, 76 percent; unicoronal, 18 percent; bicoronal and sagittal, 6 percent), and the majority had eyelid ptosis, low frontal hairline, and external ear anomalies. Thirty-one patients had received surgical intervention. Nine of 26 patients (35 percent) with at least 12 months of follow-up after primary intervention and eight of 19 patients (42 percent) with at least 5 years of follow-up developed intracranial hypertension necessitating secondary calvarial surgery. CONCLUSIONS: Despite standard surgical intervention, patients with Saethre-Chotzen syndrome have a high rate (35 to 42 percent) of recurrent intracranial hypertension necessitating further surgical expansion. All patients with either bicoronal synostosis or unicoronal synostosis with syndromic features should be screened for TWIST1 mutations, as this confers a greater risk than nonsyndromic synostosis of the same sutures. Regular follow-up throughout the childhood years is essential.

Skin sparing mastectomy and immediate breast reconstruction.

OBJECTIVE: To evaluate skin sparing mastectomy(SSM) and immediate breast reconstruction(IBR) in terms of the survival, chances of recurrence, aesthetic restoration and prevention of psychosocial problems. DESIGN: An interventional study. PLACE AND DURATION OF STUDY: The Department of Plastic and Reconstructive Surgery, CMH, Rawalpindi from November 1998 to November 2003. MATERIALS AND METHODS: Twenty-eight patients of breast cancer, included in the study, were discussed in a Multidisciplinary Breast Clinic. Detailed metastatic work-up was performed. In all patients SSM with en-bloc level II axillary clearance and IBR was done. RESULTS: The patients' age ranged between 25-46 years. Two patients (7%) were nullipara. Tumor size was T1 in 10 (36%) and T2 in 18 patients (64%). In all the patients a circum-areolar incision was used. A contralateral uni-pedicled TRAM flap was used in 24 (86%) and latissimus dorsi flap in 4 patients (14%). All the flaps survived completely. There was marginal necrosis of native skin flaps in 03 (10.5%), infection in 03 (10.5%), axillary seroma in 03 (10.5%) and abdominal seroma in 01 patient (3.5%). As late complication 5 patients (19%) developed fat necrosis. Adjuvant chemotherapy was given in 6 (21%) and adjuvant radiotherapy in 4 patients (14%). No recurrence encountered in maximum follow-up . We found an excellent aesthetic restoration in 23 (82%), good in 1 (3.5%) and fair in 4 patients (14%). CONCLUSION: SSM for patients with early breast cancer is an oncologically safe procedure. IBR can greatly reduce the psychological trauma associated with breast loss including diminished feelings of feminity, decreased libido, social behavior, sense of mutilation and depression.